“The CQC was set a difficult and complex task and it is not surprising that it has sometimes failed to meet the demands on it. It has done some good work, for instance we welcomed the decision to produce an annual report on the use of the Mental Health Act. But concerns still remain, notably that there are not enough visits and inspections of mental health and learning disability services, and there are too few Second Opinion Appointed Doctors (SOADs) to operate the Mental Health Act effectively.

We must make sure that we never again allow the appalling practice that was found at Winterbourne View, where staff have admitted to physically and verbally abusing patients. The CQC must do more to ensure that the safeguards for people detained under the Mental Health Act and supported under the Mental Capacity Act are fully complied with by local services.

In particular we strongly endorse the recommendations around safeguarding and risk. Even within the strongest governance framework, it is ultimately the front-line staff, their training and culture that requires the greatest scrutiny and focus.”